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In 25% of patients presenting with embolic stroke, a cause is not determined. Atrial fibrillation (AF) is a commonly identified mechanism of stroke in this population, particularly in older patients. Conventional investigations are used to detect AF, but can we predict AF in this population and generally? We performed a systematic review to identify potential predictors of AF on 12-lead electrocardiogram (ECG).MethodWe conducted a search of EMBASE and Medline databases for prospective and retrospective cohorts, meta-analyses or case-control studies of ECG abnormalities in sinus rhythm predicting subsequent atrial fibrillation. We assessed quality of studies based on the Newcastle-Ottawa scale and data were extracted according to PRISMA guidelines.ResultsWe identified 42 studies based on our criteria. ECG patterns that predicted the risk of developing AF included interatrial block, P-wave terminal force lead V1, P-wave dispersion, abnormal P-wave-axis, abnormal P-wave amplitude, prolonged PR interval, left ventricular hypertrophy, QT prolongation, ST-T segment abnormalities and atrial premature beats. Furthermore, we identified that factors such as increased age, high CHADS-VASC, chronic renal disease further increase the positive-predictive value of some of these parameters. Several of these have been successfully incorporated into clinical scoring systems to predict AF.ConclusionThere are several ECG abnormalities that can predict AF both independently, and with improved predictive value when combined with clinical risk factors, and if incorporated into clinical risk scores. Improved and validated predictive models could streamline selection of patients for cardiac monitoring and initiation of oral anticoagulants.

Background Adherence to secondary prevention medications following acute coronary syndromes (ACS) is a predictor of future major adverse cardiovascular events. Underutilisation of these medications is associated with higher risk of major adverse cardiovascular events globally. Aim To explore the effects of a telehealth cardiology pharmacist clinic on patient adherence to secondary prevention medications in the 12 months following ACS. Method Retrospective matched cohort study within a large regional health service comparing patient populations before and after implementation of pharmacist clinic with 12-month follow up. Patients who received percutaneous coronary intervention for ACS were consulted by the pharmacist at 1, 3- and 12-months. Matching criteria included age, sex, presence of left ventricular dysfunction and ACS type. Primary outcome was difference in adherence in adherence at 12 months post ACS. Secondary outcomes included major adverse cardiovascular events at 12 months and validation of self-reported adherence using medication possession ratios from pharmacy dispensing records. Results There were 156 patients in this study (78 matched pairs). Analysis of adherence at 12 months demonstrated an absolute increase in adherence by 13% (31 vs. 44%, p = 0.038). Furthermore, sub-optimal medical therapy (less than 3 ACS medication groups at 12 months) reduced by 23% (31 vs. 8%, p = 0.004). Conclusion This novel intervention significantly improved adherence to secondary prevention medications at 12 months, a demonstrated contributor to clinical outcomes. Primary and secondary outcomes in the intervention group were both statistically significant. Pharmacist-led follow up improves adherence and patient outcomes.

Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined.We analysed data from the multicentre Melbourne Interventional Group Registry from 2014-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index.13,286 procedures were included, with 800 (6.0%) patients in AF and 12,486 (94.0%) in SR. Compared to SR, patients with AF were older (72.9±10.9 vs 64.1±12.0 p0.001) and more likely to have comorbidities including diabetes mellitus (31.3% vs 25.0% p0.001), hypertension (74.4% vs 65.1% p0.001) and moderate to severe left ventricular systolic dysfunction (36.6% vs 19.5% p0.001). Atrial fibrillation was associated with an increased risk of in-hospital mortality (11.0% vs 2.5% p0.001) and MACE (composite of all-cause mortality, myocardial infarction, or target vessel revascularisation) (11.9% vs 4.2% p0.001). In-hospital major bleeding was more common in the AF group (3.1% vs 1.0% p0.001). On Cox proportional hazards modelling, AF was an independent predictor of long-term mortality (adjusted HR 1.38 95% CI 1.11-1.72 p0.004) at a mean follow-up of 2.3±1.5 years.Preprocedural AF is common among patients presenting for PCI. Preprocedural AF is associated with high-rates of comorbid illnesses and portends higher risk of short- and long-term outcomes including mortality underscoring the need for careful evaluation of its risks prior to PCI.

The short- and long-term implications of identifying totally occluded culprit coronary arteries (TOCCA) in patients presenting with non-ST-elevation myocardial infarction (NSTEMI) have not been well studied. This study compares clinical characteristics, short- and long-term outcomes of patients with NSTEMI identified with TOCCA to that of patients with non-TOCCA undergoing percutaneous coronary intervention (PCI). We analyzed data from patients with NSTEMI undergoing single-vessel PCI within the Melbourne Interventional Group multi-center registry between 2005 and 2017. Those with TOCCA were compared to those with non-TOCCA. The primary endpoint was 30-day major adverse cardiac events (MACE). Secondary endpoints included 12-month MACE and long-term mortality. A total of 6,829 patients with NSTEMI had single-vessel PCI of which 954 (14%) had TOCCA. Most TOCCA were non-left anterior descending (right coronary artery 39% versus circumflex 33% versus left anterior descending 26%; p

Background Patient selection and procedural characteristics continue to evolve in percutaneous coronary intervention (PCI). Australian data on long-term trends and outcomes are limited. This study aimed to identify long-term temporal trends in patient characteristics and outcomes in a large Australian PCI cohort. Methods We analysed data from 41,146 PCI procedures included in the multi-centre Melbourne Interventional Group registry to determine trends in patient characteristics, procedural practices and outcomes from 2005 to 2018. Procedures were divided into 2-yearly periods for trends analysis. Results Temporal trends in patient characteristics showed increases in age, proportion of males, rates of obesity, insulin-requiring diabetes mellitus, current smoking, obstructive sleep apnoea and prior PCI (all Ptrend Conclusions Over the last 14 years, Australian PCI procedural complexity and patient risk profiles have increased. Higher mortality rates appear to relate to increased patient risk profile rather than procedural factors.

BACKGROUND: Data on the patient characteristics and health outcomes of Indigenous Australians having revascularisation for treatment of coronary artery disease are scarce. The aim of this study was to assess differences in patient characteristics, presentations, and outcomes among Indigenous and non-Indigenous Australians having percutaneous coronary intervention (PCI) in urban and larger regional centres in Victoria, Australia. METHODS: In this multicentre, prospective, observational cohort study, data were prospectively collected from six government-funded tertiary hospitals in the state of Victoria, Australia. The Melbourne Interventional Group PCI registry was used to identify patients having PCI at Victorian metropolitan and large regional hospitals between Jan 1, 2005, and Dec 31, 2018. The primary outcome was long-term mortality. Secondary outcomes were 30 day mortality and 30 day major adverse cardiovascular events (MACE), defined as a composite endpoint of death, myocardial infarction, and target-vessel revascularisation. Regression analyses, adjusted for clinically relevant covariates and geographical and socioeconomic indices, were used to establish the influence of Indigenous status on these study outcomes. FINDINGS: 41 146 patient procedures were entered into the registry, of whom 179 (0·4%) were recorded as identifying as Indigenous Australian, 39 855 (96·9%) were not Indigenous Australian, and 1112 (2·7%) had incomplete data regarding ethnicity and were excluded. Compared with their non-Indigenous counterparts, Indigenous patients were younger, more often women, and more likely to have comorbidities. Indigenous Australians were also more likely to live in a regional community and areas of socioeconomic disadvantage. Procedural success and complication rates were similar for Indigenous and non-Indigenous patients having PCI. At 30 day follow-up, Indigenous Australians were more likely to be taking optimal medical therapy, although overall follow-up rates were lower and prevalence of persistent smoking was higher. Multivariable analysis showed that Indigenous status was independently associated with increased risk of long-term mortality (hazard ratio 2·49, 95% CI 1·79-3·48; p

Background: Optimal medical therapy (OMT) following acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI) is a predictor of future major adverse cardiovascular events (MACE). Underutilisation of OMT is associated with higher risk of MACE within Australian populations. Aims: Effects of a telehealth cardiology pharmacist clinic (TCPC) on patient adherence to OMT and MACE in patients who received PCI for ACS. Methods: Retrospective matched cohort study within a large regional health service comparing patient populations before and after implementation of post-PCI TCPC with twelve-month follow up. Patients who received PCI for ACS were consulted by the pharmacist at one, three- and twelve-months’. Matching criteria included age, sex, presence of left ventricular dysfunction and ACS type. Primary outcome was difference in adherence to OMT at twelve months post PCI. Secondary outcomes included 4-point MACE at twelve months and validation of self-reported adherence using medication possession ratios from pharmacy dispensing records. Results: There were 156 patients in this study (78 matched pairs). Analysis of adherence to OMT at twelve months demonstrated an absolute increase in adherence to OMT by 13% (31 vs. 44%, p = 0.038). Furthermore, sub-optimal medication therapy (less than ACS medication groups at twelve months) reduced by 23% (31–8%, p = 0.004). MACE at twelve months reduced by 23% (31 vs.8% p = 0.004). Conclusions: This novel intervention significantly improved adherence at to OMT at twelve months; a demonstrated contributor to clinical outcomes. Primary and secondary outcomes in the intervention group were both statistically significant. Pharmacist-led follow up is both cost effective and improves patient outcomes.

Introduction The dual antiplatelet therapy (DAPT) score was developed to identify patients more likely to derive benefit (score ≥2) or harm (score Purpose We sought to examine long-term mortality after PCI by the DAPT score in patients treated with DAPT per local guidelines. Methods We examined data from the MIG PCI database from 2005 to 2018 in whom the DAPT score could be derived and grouped them as score ≥2 or Results Out of 27,740 patients in the study, 9,401 (33.9%) had DAPT score ≥2. They were younger and included more females and higher prevalence of renal impairment. DAPT score ≥2 patients had higher in-hospital major bleeding, 30-day mortality, MI and target vessel revascularisation. DAPT score ≥2 patients had lower long-term survival to 12 years (p Conclusion A third of all-comer PCI patients had DAPT score ≥2 with greater short-term risk of ischaemic and bleeding outcomes, as well as long-term mortality. Theoretically, those with DAPT score ≥2 would benefit from longer duration of DAPT as ischaemic risk outweighs bleeding risk. However, given our finding of increased short-term bleeding risk and long-term mortality, dynamic bleeding risk assessment should be undertaken to guide pharmacotherapy strategies. Funding Acknowledgement Type of funding sources: None.

To evaluate the effect of age in an all-comers population undergoing percutaneous coronary intervention (PCI).Age is an important consideration in determining appropriateness for invasive cardiac assessment and perceived clinical outcomes.We analysed data from 29,012 consecutive patients undergoing PCI in the Melbourne Interventional Group (MIG) registry between 2005 and 2017. 25,730 patients80 year old (78% male, mean age 62±10 years; non-elderly cohort) were compared to 3,282 patients ≥80 year old (61% male, mean age 84±3 years; elderly cohort).The elderly cohort had greater prevalence of hypertension, diabetes and previous myocardial infarction (all p0.001). Elderly patients were more likely to present with acute coronary syndromes, left ventricular ejection fraction45% and chronic kidney disease (p0.0001). In-hospital, 30-day and long-term all-cause mortality (over a median of 3.6 and 5.1 years for elderly and non-elderly cohorts, respectively) were higher in the elderly cohort (5.2% vs. 1.9%; 6.4% vs. 2.2%; and 43% vs. 14% respectively, all p0.0001). In multivariate Cox regression analysis, estimated glomerular filtration rate (eGFR)30 mL/min/1.73 mThe elderly cohort is a high-risk group of patients with increasing age being associated with poorer long-term mortality. Age, thus, should be an important consideration when individualising treatment in elderly patients.

BACKGROUND: Optimal secondary prevention pharmacotherapy is the cornerstone of post-acute coronary syndrome (ACS) management. The prognostic impact of not receiving five guideline-recommended therapies is poorly described. AIM: To ascertain the prognostic significance of suboptimal pharmacotherapy in ACS survivors. METHODS: Consecutive patients with ACS from the Melbourne Interventional Group registry who were alive at 30 days following their index percutaneous coronary intervention were included. Patients were divided into three categories based on the number of secondary prevention medications prescribed. The optimal medical therapy (OMT), near-optimal medical therapy (NMT), suboptimal medical therapy (SMT) groups were prescribed 5, 4 and ≤ 3 medications, respectively. Primary endpoint was long-term mortality. Cox-proportional hazard modelling was undertaken to assess independent predictors of survival. RESULTS: Of the 9375 patients included, 5678 (60.6%) received OMT, 2903 (31.0%) received NMT and 794 (8.5%) received SMT. Patients receiving SMT were older, more likely to be female and had higher burden of comorbidities (renal impairment, congestive heart failure, diabetes, peripheral vascular disease; P

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without RA. The Melbourne Interventional Group PCI registry (2005 to 2018) was used to identify 756 patients with RA. Outcomes were compared with the remaining cohort (n = 38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnea, chronic lung disease, myocardial infarction, and renal impairment, whereas rates of dyslipidemia and current smoking were lower, all p

AimsThere is a paucity of evidence supporting routine beta blocker (BB) use in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). The aim of this study was to evaluate BB use post PCI and its association with mortality. Furthermore, the study aimed to evaluate the association between BB and mortality in the subgroups of patients with left ventricular ejection fraction (LVEF) 50%.MethodsUsing a large PCI registry, data from patients with ACS between January 2005 and June 2017 who were alive at 30 days were analysed. Those patients taking BB at 30 days were compared with those who were not taking BB. The primary outcome was all-cause mortality. The mean follow-up was 5.3±3.5 years.ResultsOf the 17 562 patients, 83.3% were on BB. Mortality was lower in the BB group (13.1% vs 19.5%, p=0.0001). Multivariable Cox proportional hazards model showed that BB use was associated with lower overall mortality (adjusted HR 0.87, 95% CI 0.78 to 0.97, p=0.014). In the subgroup analysis, BB use was associated with reduced mortality in LVEF 50% (adjusted HR 1.03, 95% CI 0.87 to 1.21, p=0.74).ConclusionBB use remains high and is associated with reduced mortality. This reduction in mortality is primarily seen in those with reduced ejection fraction, but not in those with preserved ejection fraction.

Background There is no universally accepted age cut-off for defining young strokes. Aims We aimed to determine, based on the profile of young stroke patients in our regional centre, an appropriate age cut-off for young strokes. Methods A retrospective analysis of all ischaemic stroke patients admitted to our centre from 2015 to 2017. We identified 391 ischaemic stroke patients; 30 patients between the ages of ≤50, 40 between 51-60 inclusive and 321 ≥ 61 years of age. We collected data on demographic profiles, risk factors and stroke classification using the Trial of Org 10 172 in Acute Stroke Treatment criteria. Results We found significant differences between the ≤50 and ≥61 age groups for most of the risk factors and similarities between the 51-60 inclusive and ≥ 61 age groups. At least one of the six risk factors assessed in the study was present in 86.7% of the youngest group, 97.5% of the intermediate age group and 97.2% in the oldest group. In terms of the mechanisms of stroke, the youngest and oldest age groups in our study differed in the prevalence of cryptogenic, cardioembolic and other causes of stroke. The middle and older age groups had similar mechanisms of stroke. Conclusions The prevalence of vascular risk factors and mechanisms of stroke likewise differed significantly across age groups. This study suggests that 50 years is an appropriate age cut-off for defining young strokes and reinforces the importance of primary prevention in all age groups.

Systems of care have been established to ensure patients with ST-elevation myocardial infarction (STEMI) get timely access to primary percutaneous coronary intervention (PPCI). In this study, we evaluated whether patients undergoing PPCI both in-hours and out-of-hours experience similar care and clinical outcomes.Of 9,865 patients who underwent PCI for STEMI from 2005 to 2016 and were enrolled in the multi-centre Melbourne Interventional Group registry, patients who had initially presented to a non-PCI capable hospital, received thrombolysis or presented12hourspost-symptom onset were excluded. Our final study cohort of 4,590 patients were dichotomised by whether PPCI was performed in-hours or out-of-hours, and compared. The primary outcome was 30-day mortality.The in-hours group included 1,865 patients (40.6%) while 2,725 patients (59.4%) had out-of-hours PPCI. Patients presenting out-of-hours had longer median door-to-balloon time (DTBT; 83 [IQR 61-109] vs. 60 [IQR 41-88] mins, p0.01) and were more likely to receive a drug-eluting stent (p=0.001). Procedural characteristics were otherwise similar although rates of radial access were low overall (18.4%). No differences in in-hospital, 30-day or 12-month mortality were observed between the groups (p=NS). On Cox proportional hazards modelling, out-of-hours presentation was not an independent predictor of 30-day mortality (HR 0.94, 95% CI 0.71-1.22). A landmark analysis of data from 2012 did not change the primary outcome.Despite a slightly longer DTBT, patients undergoing PPCI out-of-hours experienced similar care and clinical outcomes to the in-hours group. Given the majority of patients with STEMI present out-of-hours, these data have implications for STEMI systems of care.

In cardiogenic shock with severe left main coronary artery stenosis (LM), limited information exists on short and longer-term outcomes. We sought to determine the outcomes of unprotected LM PCI in cardiogenic shock.Excluding patients with previous CABG, consecutive patients undergoing PCI in cardiogenic shock from the Melbourne Intervention Group registry between 2005 and 2013 were analysed. Those post LM PCI were compared to those post non-LM PCI. Patient and procedural data were collected with 30-day and 12-month follow-up. Australian National Death Index linkage was performed for long-term mortality analysis.After excluding previous CABG, 18,069 procedures were performed during 1st January 2005 to 30th November 2013, 601 procedures in the setting of cardiogenic shock. Of these, 45 were performed to an isolated LM and 556 to a non-LM. Those with LM PCI were older and more likely to have a baseline left ventricular ejection fraction (LVEF) of45%. The in-hospital, 30-day, 12-month and long-term mortality to 9 years in cardiogenic shock after LM PCI was 64.4%, 66.7%, 73.3% and 80.0% compared to 36.5%, 36.9%, 40.5% and 46.0%, after non-LM PCI (p 0.001). On multivariate analysis, LM PCI was a significant independent predictor of long-term mortality (HR1.59, 95%CI 1.00-2.53, p = 0.048). Landmark analysis of survivors to discharge found the long-term mortality of LM PCI approaches 60% compared to 27% for those with non-LM PCI (p = 0.003).Long-term outcomes after PCI to LM in cardiogenic shock are poor, with much of the excess in mortality occurring early. However, reasonable long-term survival was found beyond the initial high-risk period.

Background There is a long-held belief in the association between the full moon and extremes of human behaviour and adverse health consequences. Small-scale studies are conflicting; however, most suggest no clear association between lunar phase and occurrence of acute coronary syndromes. Aims To evaluate the impact of the lunar phase, and in particular, the full moon phase, on the incidence and outcomes among ST-elevation myocardial infarction (STEMI) cases undergoing percutaneous coronary intervention (PCI). Methods We conducted a multi-centre retrospective study from the Melbourne Interventional Group registry, including 7570 STEMI cases from six tertiary centres over a 12-year study period in Victoria, Australia, and performed statistical analysis using Stata software. Primary outcomes studied were the incidence of STEMI, the occurrence of major adverse cardiac and cerebrovascular events and mortality at 1 and 5 years in cases of STEMI undergoing primary or rescue percutaneous coronary intervention during the full moon between 2005 and 2017 in Victoria, Australia. Results This study demonstrated neither significant difference in STEMI incidence (P = 0.61) nor of major adverse cardiovascular events across all lunar phases. Subgroup analysis confirmed no difference in outcomes during the full moon compared to a composite of other lunar phases.Kaplan-Meier survival estimates showed similar 30-day outcomes across lunar phases (P = 0.35) and when comparing full moon to a composite of other lunar phases (P = 0.45). Similarly, there was no significant difference in survival at 1 and 5 years between lunar phases (P = 0.68) or compared to the full moon phase (P = 0.51). Conclusions This study showed no significant difference in the incidence or cardiovascular outcomes and survival in patients with STEMI undergoing primary or rescue percutaneous coronary intervention during the lunar phases.

Previous large multi-centre randomised controlled trials have not provided clear benefit with routine intracoronary thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI).To determine whether there is a difference in outcomes with the use of manual TA prior to PCI, compared with PCI alone in a cohort of patients with STEMI.We analysed data from 6270 consecutive patients undergoing primary PCI for STEMI prospectively enrolled in the Melbourne Interventional Group registry between 2007 and 2018. Multivariable analysis was performed to determine predictors of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and long-term mortality.We compared 1621 (26%) patients undergoing primary PCI with TA to 4649 (74%) patients undergoing PCI alone. Male gender (81% vs 78%; P 0.01), younger age (61 vs 63 years; P = 0.03), GP-IIb/IIIa use (76% vs 58%, P 0.01), and current smoking (40% vs 36%; P 0.01) were more common in the TA group. TA was more likely to be used in patients with complex lesions (83% vs 66%; P 0.01) with TIMI 0 flow (77% vs 56%; P 0.01). No significant difference in post-procedural TIMI flow, stroke, 30-day mortality, or long-term mortality were identified. Multivariable analysis demonstrated a reduction in 30-day MACCE (hazard ratio (HR) 0.75; confidence interval (CI) 0.63-0.89; P 0.01) in the TA group, but was not associated with long-term mortality (HR 0.98; CI 0.85-1.1; P = 0.73).The use of TA in patients undergoing primary PCI for STEMI was not associated with improved short or long-term mortality when compared with PCI alone.

IntroductionLow health literacy is common in people with cardiovascular disease and may be one factor that affects an individual’s ability to maintain secondary prevention health behaviours following myocardial infarction (MI). However, little is known about the association between health literacy and longer-term health outcomes in people with MI. The ENhancing HEAlth literacy in secondary pRevenTion of cardiac evENts (ENHEARTEN) study aims to examine the relationship between health literacy and a number of health outcomes (including healthcare costs) in a cohort of patients following their first MI. Findings may provide evidence for the significance of health literacy as a predictor of long-term cardiac outcomes.Methods and analysisENHEARTEN is a multicentre, prospective observational study in a convenience sample of adults (aged >18 years) with their first MI. A total of 450 patients will be recruited over 2 years across two metropolitan health services and one rural/regional health service in Victoria, Australia. The primary outcome of this study will be all-cause, unplanned hospital admissions within 6 months of index admission. Secondary outcomes include cardiac-related hospital admissions up to 24 months post-MI, emergency department presentations, health-related quality of life, mortality, cardiac rehabilitation attendance and healthcare costs. Health literacy will be observed as a predictor variable and will be determined using the 12-item version of the European Health Literacy Survey (HLS-Q12).Ethics and disseminationEthics approval for this study has been received from the relevant human research ethics committee (HREC) at each of the participating health services (lead site Monash Health HREC; approval number: RES-21-0000-242A) and Services Australia HREC (reference number: RMS1672). Informed written consent will be sought from all participants. Study results will be published in peer-reviewed journals and collated in reports for participating health services and participants.Trial registration numberACTRN12621001224819.

Purpose During the COVID-19 pandemic, widespread public health measures were implemented to control community transmission. The association between these measures and health-related quality of life (HRQOL) among patients following percutaneous coronary intervention has not been studied. Methods We included consecutive patients undergoing percutaneous coronary intervention (PCI) in the state-wide Victorian Cardiac Outcomes Registry between 1/3/2020 and 30/9/2020 (COVID-19 period; n = 5024), with a historical control group from the identical period one year prior (control period; n = 5041). HRQOL assessment was performed via telephone follow-up 30 days following PCI using the 3-level EQ-5D questionnaire and Australian-specific index values. Results Baseline characteristics were similar between groups, but during the COVID-19 period indication for PCI was more common for acute coronary syndromes. No patients undergoing PCI were infected with COVID-19 at the time of their procedure. EQ-5D visual analogue score (VAS), index score, and individual components were higher at 30 days following PCI during the COVID-19 period (all P

Background Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularisation. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the SHOCK-II trial in 2012 found no survival benefit. Purpose This study aimed to determine the trends in IABP use in patients with MI-CS undergoing percutaneous intervention (PCI) over time and characteristics associated with use. Methods Between 2005–2018, patients presenting with MI-CS that underwent percutaneous coronary intervention (PCI) at a hospital participating in the Melbourne Interventional Group Registry were included. The primary outcome was the trend in IABP use over time. Secondary outcomes included mortality, 30-day MACCE (major adverse cardiovascular and cerebrovascular events) and predictors of outcome, determined via logistic regression. Results Of the 1,110 patients identified, IABP was used in 478 (43%). IABP was used more in patients with left main and left anterior descending culprit lesions (62% vs. 46%), lower ejection fraction ( Conclusions Consistent with the SHOCK II trial, IABP use is not associated with reduced short- or long-term mortality, but in this study was associated with increased short-term adverse events. IABP use is declining, but is still used in sicker patients with greater myocardium at risk, given limited alternatives. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Melbourne interventional group

Aims The use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II-receptor blockers (ARBs) post-myocardial infarction (MI) is supported by evidence based on trials performed in the thrombolysis era. This was prior to primary percutaneous coronary intervention (PCI) being routine practice, and with little direct evidence for the use of these medications in patients with preserved left ventricular (LV) function. This study sought to determine whether there is an association between ACEi/ARB use after PCI for acute coronary syndrome (ACS) and long-term all-cause mortality, with a particular focus on patients with preserved LV function. Methods This multicentre, observational study evaluated prospectively collected data of 21,388 patients (> 18 years old) that underwent PCI for NSTEMI and STEMI between 2005 and 2018, and were alive at 30 day follow-up. Results In total, 83.8% of patients were using ACEi/ARBs. Kaplan–Meier analysis demonstrated ACEi/ARB use was associated with a significantly lower mortality in the entire cohort (15.0 vs. 22.7%; p p Conclusion ACEi/ARB therapy post-PCI is associated with significantly lower long-term mortality in patients with reduced and preserved LV function. These findings provide contemporary evidence for using these agents in the current era of routine primary PCI, including those with preserved EF. Graphical abstract

Background High systolic blood pressure (SBP) increases cardiac afterload, whereas low diastolic blood pressure (DBP) may lead to impaired coronary perfusion. Thus, wide pulse pressure (high systolic, low diastolic [HSLD]) may contribute to myocardial ischemia and also be a predictor of adverse cardiovascular events. Objectives The purpose of this study was to determine the relationship between pre-procedural blood pressure and long-term outcome following percutaneous coronary intervention (PCI). Methods The study included 10,876 consecutive patients between August 2009 and December 2016 from the Melbourne Interventional Group registry undergoing PCI with pre-procedural blood pressure recorded. Patients with ST-segment elevation myocardial infarction, cardiogenic shock, and out-of-hospital cardiac arrest were excluded. Patients were divided into 4 groups according to SBP (high ≥120 mm Hg, low 70 mm Hg, low ≤70 mm Hg). Results Mean pulse pressure was 60 ± 21 mm Hg. Patients with HSLD were older and more frequently women, with higher rates of hypercholesterolemia, renal impairment, diabetes, and multivessel and left main disease (all p ≤ 0.0001). There was no difference in 30-day major adverse cardiac events, but at 12 months the HSLD group had a greater incidence of myocardial infarction (p = 0.018) and stroke (p = 0.013). Long-term mortality was highest for HSLD (7.9%) and lowest for low systolic, high diastolic (narrow pulse pressure) at 2.1% (p = 0.0002). Cox regression analysis demonstrated significantly lower long-term mortality in the low systolic, high diastolic cohort (hazard ratio: 0.50; 99% confidence interval: 0.25 to 0.98; p = 0.04). Conclusions Pulse pressure at the time of index PCI is associated with long-term outcomes following PCI. A wide pulse pressure may serve as a surrogate marker for risk following PCI and represents a potential target for future therapies.

ObjectivesTo determine if a digital communication app improves care timelines for patients with suspected acute stroke/ST-elevation myocardial infarction (STEMI).DesignReal-world feasibility study, quasi-experimental design.SettingPrehospital (25 Ambulance Victoria branches) and within-hospital (2 hospitals) in regional Victoria, Australia.ParticipantsParamedics or emergency department (ED) clinicians identified patients with suspected acute stroke (onset InterventionThe Pulsara communication app provides secure, two-way, real-time communication. Assessment and treatment times were recorded for 12 months (May 2017–April 2018), with timelines compared between ‘Pulsara initiated’ (Pulsara) and ‘not initiated’ (no Pulsara).Primary outcome measureDoor-to-treatment (needle for stroke, balloon for STEMI) Secondary outcome measures: ambulance and hospital processes.ResultsStroke (no Pulsara n=215, Pulsara n=389) and STEMI (no Pulsara n=76, Pulsara n=171) groups were of similar age and sex (stroke: 76 vs 75 years; both groups 50% male; STEMI: 66 vs 63 years; 68% and 72% male). When Pulsara was used, patients were off ambulance stretcher faster for stroke (11(7, 17) vs 19(11, 29); p=0.0001) and STEMI (14(7, 23) vs 19(10, 32); p=0.0014). ED door-to-first medical review was faster (6(2, 14) vs 23(8, 67); p=0.0001) for stroke but only by 1 min for STEMI (3 (0, 7) vs 4 (0, 14); p=0.25). Door-to-CT times were 44 min faster (27(18, 44) vs 71(43, 147); p=0.0001) for stroke, and percutaneous intervention door-to-balloon times improved by 17 min, but non-significant (56 (34, 88) vs 73 (49, 110); p=0.41) for STEMI. There were improvements in the proportions of patients treated within 60 min for stroke (12%–26%, p=0.15) and 90 min for STEMI (50%–78%, p=0.20).ConclusionsIn this Australian-first study, uptake of the digital communication app was strong, patient-centred care timelines improved, although door-to-treatment times remained similar.

There is paucity of data examining long-term outcomes of premature coronary artery disease (CAD). We aimed to investigate the short- and long-term clinical outcomes of patients with premature CAD treated by percutaneous coronary intervention (PCI) compared to older cohorts. We analyzed data from 27,869 patients who underwent PCI from 2005-2017 enrolled in a multicenter PCI registry. Patients were divided into three age groups: young group (≤ 45 years), middle-age group (46-65 years) and older group (>65 years). There were higher rates of current smokers in the young (n = 1,711) compared to the middle-age (n = 12,830) and older groups (n = 13,328) (54.2% vs 34.6% vs 11%) and the young presented more frequently with acute coronary syndrome (ACS) (78% vs 66% vs 62%), all p

There are conflicting data on whether patients with insulin-treated diabetes mellitus (ITDM) have poorer outcomes compared with non-insulin treated diabetic (non-ITDM) patients following percutaneous coronary intervention (PCI). We therefore compared clinical outcomes following PCI in ITDM versus non-ITDM patients. We prospectively collected data on 4,579 patients with diabetes underwent PCI between 2005 and 2014 in a large multicenter registry and dichotomized them as having ITDM (n = 1,111) or non-ITDM (n = 3,468). The non-ITDM group was further divided into diet control only (diet-DM; n = 786) and those taking oral hypoglycemic agents (OHG-DM; n = 2,639), and clinical outcomes were compared with ITDM patients. Median follow-up for long-term mortality was 4.2 years (IQR 2.0 to 6.6 years). ITDM patients were more likely to be female, obese, and have severe renal impairment (all p

Background Left ventricular dysfunction and ischaemic heart disease are common amongst women, however, women tend to present later and are less likely to receive guideline-directed medical therapy compared to their male counterparts. Purpose To investigate if a sex discrepancy exists for optimal medical therapy (OMT) and long-term mortality in a cohort of patients with known ischaemic heart disease (IHD) and left ventricular dysfunction. Methods We analysed prospectively collected data from a multicentre registry database collected between 2005–2018 on pharmacotherapy 30-days post percutaneous coronary intervention (PCI) in 13,015 patients with left ventricular ejection fraction (LVEF) Results Mean age was 65±12 years; women represented 20.2% (2,634) of the cohort. Women were on average 5 years older, had higher average BMI, higher rates of hypertension, diabetes, renal dysfunction, prior stroke and rheumatoid arthritis. Men were more likely to have sleep apnoea, be current/ex-smokers and to have had prior myocardial infarction, PCI and bypass surgery. Overall, 72.3% (9,411) of patients were on OMT, which was similar between sexes (72.7% in women vs. 72.2% in men, p=0.58). Rates of BB therapy were similar between sexes (85.2% vs. 84.5%, p=0.38), while women were less likely to be on an ACEi/ARB (80.4% vs. 82.4%, p=0.02) and more likely to be on a MRA (12.1% vs. 10.0%, p=0.003). Amongst those with LVEF ≤35% (n=1,652), BB (88.7% vs. 87.3%, p=0.46), ACEi/ARB (83.3% vs. 82.1%, p=0.59) and MRA use (32.5% vs. 33.3%, p=0.78) was comparable. Aspirin use was similar between sexes (95.3% vs. 95.9%, p=0.12), while women were less likely to be on statin therapy (93.5% vs. 95.3%, p Conclusion From this large multicentre registry, we found similar rates of guideline-directed pharmacotherapy for left ventricular dysfunction between sexes, however women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality amongst women is likely due to differing baseline risk, given that adjusted mortality was similar between sexes. Kaplan-Meier Survival Analysis Funding Acknowledgement Type of funding source: None

Background Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Despite this, data regarding long-term outcomes following percutaneous coronary intervention (PCI) are limited. Methods We identified 756 patients with RA from the Melbourne Interventional Group PCI registry (2005–2018) and compared outcomes to the remaining cohort (N=38,579). Cox regression analysis was performed to assess risk of adverse cardiac events including long-term mortality (derived from linkage with the National Death Index [NDI]). Results Patients with RA were older (68.9±10.0 vs. 64.6±12.0 years) and more often female (40% vs. 23%), with higher rates of hypertension (70% vs 67%), previous stroke (9% vs 6%), peripheral vascular disease (9% vs 6%), obstructive sleep apnoea (10% vs 5%), chronic lung disease (22% vs 12%), prior myocardial infarction (32% vs 27%), and impaired renal function (eGFR20mm in 39% vs 35%), and rates of no reflow were higher (5% vs 3%), all p Conclusions Patients with RA undergoing PCI have more comorbidities and longer, more complex coronary lesions. After adjustment, risk of short-term adverse outcomes are similar, while risk of long-term mortality is higher, particularly among patients with acute coronary syndromes. Funding Acknowledgement Type of funding source: None

Aims We sought to investigate if sex disparity exists for secondary prevention pharmacotherapy following acute coronary syndrome (ACS) and impact on long-term clinical outcomes. Methods and results We analysed data on medical management 30-day post-percutaneous coronary intervention (PCI) for ACS in 20 976 patients within the multicentre Melbourne Interventional Group registry (2005–2017). Optimal medical therapy (OMT) was defined as five guideline-recommended medications, near-optimal medical therapy (NMT) as four medications, sub-optimal medical therapy (SMT) as ≤3 medications. Overall, 65% of patients received OMT, 27% NMT and 8% SMT. Mean age was 64 ± 12 years; 24% (4931) were female. Women were older (68 ± 12 vs. 62 ± 12 years) and had more comorbidities. Women were less likely to receive OMT (61% vs. 66%) and more likely to receive SMT (10% vs. 8%) compared to men, P Conclusion Women are less likely to be prescribed optimal secondary prevention medications following PCI for ACS. Lower adjusted long-term mortality amongst women suggests that as well as baseline differences between gender, optimization of secondary prevention medical therapy amongst women can lead to improved outcomes. This highlights the need to focus on minimizing the gap in secondary prevention pharmacotherapy between sexes following ACS.

Cardiovascular disease is a major burden on the health of Australians, and cardiac health disparities exist for those who live outside of metropolitan areas. Poor patient medication literacy was identified by cardiologists at a regional Victorian health service as a barrier to medication optimisation and a factor in inefficiency in their service. Studies in Australia and overseas have shown pharmacists involved in multi-disciplinary and pre-admission models result in more accurate medication histories, increased patient medication knowledge and lower medication related adverse events. This study introduced a telehealth cardiology pharmacist clinic, with the primary aim of reducing cardiologist time gathering medication information and secondary aims of investigating the patient and cardiologist experience.A cardiology pharmacist clinic was introduced where a pharmacist undertook a consultation with a patient in the days preceding their appointment with their cardiologist. The primary outcome of this study was to determine whether a cardiology pharmacist consultation undertaken prior to a cardiologist consultation reduces the time spent by the cardiologist gathering medication information. This was measured via direct observation of cardiologist consultations with and without a prior cardiology pharmacist clinic consultation. Descriptive and inferential statistics were performed to assess differences in time spent gathering the patient's medication information by the cardiologist. The secondary outcomes included differences between: the total length of cardiologist consultations, the number of cardiologist appointments with a medication uncertainty, and attendance rates for cardiologist consultations with and without a prior cardiology pharmacist clinic consultation. Other secondary outcomes included a quantitative survey assessing patient satisfaction with the pharmacist consultation, satisfaction with telehealth, confidence in medication management. Finally, clinician perceptions of the value of the pharmacist consultation were explored via semi-structured interviews.The time spent gathering medication information immediately before, and during, the cardiologist appointment reduced from 4.66 minutes without a prior cardiology pharmacist clinic consultation to 0.66 minutes with a prior cardiology pharmacist clinic consultation (difference 4 min, 95% CI: 3.27-4.77 p≤001). There was a 4.1-minute reduction in the mean consultation length of the cardiologist appointment if a cardiology pharmacist clinic consultation occurred prior (95% CI: 1.9-6.3, p0.001). There were zero medication uncertainties (0/44) in the cardiologist appointment when the patient had a cardiology pharmacist clinic consultation compared to 51% (22/43) when no cardiology pharmacist clinic consultation had occurred. Patients with a cardiology pharmacist clinic consultation had a 5% (17/340) 'did not attend' (DNA) rate for their next cardiologist appointment. Patients who did not have a cardiology pharmacist clinic consultation had a 24% (202/855) DNA rate to their next cardiologist appointment. There was 100% patient satisfaction with the consultation provided by the cardiology pharmacist (100/100) and telehealth was considered an acceptable mode of delivery by 99% (95/96) of patients. Patients expressed an increase in their confidence to discuss their medications with their cardiologist (84% [81/96]). Benefits described by the clinicians whose patients received the service were greater confidence and ability to make treatment decisions within consultations, as well as improved patient health literacy.A cardiology pharmacist consultation undertaken prior to a cardiologist consultation reduced the time spent by the cardiologist gathering medication information. Importantly, it reduced medication uncertainty in cardiologist consultations which clinicians indicated provided them with greater confidence and ability to make treatment decisions within consultations. Patients who undertook a cardiology pharmacist clinic consultation were more likely to attend their cardiologist consultation, reducing wasted appointments. Patients were highly satisfied with the cardiology pharmacist consultation and considered telehealth an acceptable mode of delivery.

OBJECTIVES: We aimed to assess the outcomes of cardiogenic shock (CS) complicating acute coronary syndromes (ACS). BACKGROUND: CS remains the leading cause of mortality in patients presenting with ACS despite advances in care. METHODS: We studied 13,184 patients undergoing percutaneous coronary intervention (PCI) for all subtypes of ACS enrolled prospectively in a large multicentre Australian registry (Melbourne Interventional Group registry) from 2005 to 2013. All-cause mortality was obtained via linkage to the National Death Index. Patients were divided into those with and those without CS. RESULTS: Compared to the non-CS group (n = 12,548, 95.2%), the CS group (n = 636, 4.8%) had a higher proportion of out-of-hospital cardiac arrest (OHCA) (31.1 vs. 2.2%) and ST-elevation myocardial infarction (STEMI) presentation (89 vs. 34%), both p

Percutaneous coronary intervention (PCI) continues to evolve with shifting patient demographics, treatments, and outcomes. We sought to document the specific changes observed over a 9-year period in a contemporary Australian PCI cohort. The Melbourne Interventional Group is an established multicenter PCI registry in Melbourne, Australia. Data were collected prospectively with 30-day and 12-month follow-ups. Demographic, procedural, and outcome data for all consecutive patients were analyzed with a year-to-year comparison from 2005 to 2013. National Death Index linkage was performed for long-term mortality analysis; 19,858 procedures were captured over 9 years. Patient complexity and acuity increased with a higher proportion of traditional risk factors and more elderly patients who underwent PCI. Angiographic lesion complexity increased with more multivessel coronary artery disease and more American College of Cardiology/American Heart Association type B2/C lesions proceeding to PCI. The 30-day rate of death, myocardial infarction, or target vessel revascularization has not changed nor has 12-month mortality, myocardial infarction, or major adverse cardiovascular event rates. The strongest independent predictor of long-term mortality was cardiogenic shock at presentation (hazard ratio [HR] 2.95, p